Practicing functional nasal surgery in the non-urban setting: experience from a single center

Abstract Nasal airway obstruction is a prevalent chief complaint in the contemporary facial plastic surgery practice. Studies report an asymmetric distribution of plastic surgeons across the United States with a disproportionately high concentration of surgeons practicing in urban areas. The lack of elective specialist care creates unique challenges for these patients who may need to travel and dedicate time to reach a nasal surgery expert. We conducted a retrospective chart review to report our experience from practicing functional nasal surgery in such a non-urban setting in the United States. A total of 103 patients underwent functional nasal surgery (FNS) between May 2015 and August 2021 including septoplasty, inferior turbinate reduction, septorhinoplasty and nasal valve procedures. We present the epidemiological characteristics, surgical techniques used and postoperative complications and illuminate the unique characteristics of practicing FNS in the non-urban setting.


INTRODUCTION
Nasal airway obstruction (NAO) is a prevalent chief complaint in the contemporary facial plastic surgery practice. Studies report an asymmetric distribution of plastic surgeons across the United States: a disproportionately high concentration of surgeons practice in urban areas [1]. Li et al. [2] identified urban location as an independent risk factor for subsequent septorhinoplasty following initial nasal bone fracture. This ref lects the lack of elective specialist care access for these patients who may need to travel and dedicate time to reach a nasal surgery expert.

CASE SERIES / METHODS
We conducted a retrospective chart review with the approval of the Ethics Committee of our institution. A total of 103 patients underwent functional nasal surgery (FNS) between May 2015 and August 2021 including septoplasty, inferior turbinate reduction, septorhinoplasty and nasal valve procedures (CPT codes 30 520, 30 802, 30 420, 30 465). All patients had failed previous management with at least 6 weeks of intranasal steroids. All surgical procedures were performed by the lead author.
Six postoperative complications (5.8%) were reported in four patients (3.9%). These included three posterior septal perforations, two cases of severe postoperative bleeding, one infection and one case of minimal persistent bleeding that required medical attention. All septal perforations were asymptomatic. The infection manifested with minimal drainage in the mid-columellar incision and resolved with a course of antibiotics. The

DISCUSSION
Limited by the relatively small size, we report our experience from FNS in a non-urban center. About 50.4% of our patients reported history of nasal fracture, making post-traumatic FNS a major part of our practice; 40.7% of our patients were active smokers, and 17.4% reported past smoking history, numbers unparalleled to any rhinoplasty studies. A tertiary center study reported 11% active smokers and 30% previous smokers among patients undergoing nasoseptal surgery [3]. This difference may ref lect higher incidence of tobacco use in our area compared with the national incidence of smoking in adults (14% in 2019) [4]. Our complication rate was 5.8%, similar to previously reviewed (bleeding-related complications 0.2-6.7%, infection 0-4%, septal perforations 0-2.9%) [5]. Two patients had a complicated postoperative course including both postoperative bleeding and subsequent septal perforations. Only 6.7% were revision cases, perhaps indicating the hardship in reaching expert care.

CONCLUSION
Our results illuminate the unique characteristics of practicing FNS in the non-urban setting. Solid clinical expertise is required to manage these challenging patients.